Claim Appeal

If your Claim is denied or you disagree with the amount of the benefit, you have the right to have the initial determination reviewed by appealing the denial to the Trustees of the Claim Committee of the Chicago Laborers’ Welfare Fund. Your Appeal must be filed in writing at the Fund Office not more than 180 days (or 60 days for Death and Accidental Dismemberment Benefit Claims) after the date you received the letter denying your Claim.

When filing an Appeal (requesting a review of a denied Claim), note the following:

Your Appeal must be submitted in writing within the applicable timeframe.

Your Appeal must state the reasons you disagree with the Claim determination.

You must attach all copies of evidence supporting your Appeal.

You, or your designated representative, have the right to receive, upon written request, copies of all documents relevant to your Claim.

Your designated representative may be an attorney.

You have the right to challenge the denial of a Claim by filing a lawsuit in court, seeking review of the Fund’s decision under section 502(a) of ERISA. Such a lawsuit can only be filed after you have followed the Fund’s Appeal procedures.

If your Claim is denied based on an internal rule, guideline, protocol, or other similar criteria, you have the right to request a free copy of that information.

If your Claim is denied based on a Medical Necessity, Experimental Treatment, or similar exclusion or limit, you have the right to request a free copy of an explanation of the scientific or clinical judgment for the determination.

You have the right to be advised of the identity of any medical experts and you may:

Submit additional materials, including comments, statements, or documents; and

Request to review all relevant information (free of charge). A document, record or other information is considered relevant if it:

Was relied upon by the Plan in making the decision;

Was submitted, considered, or generated (regardless of whether it was relied upon); or

Appeal Review

Once your Claim is received, if you filed your Appeal on time and followed the required procedures, the Claim Department’s management staff reviews it first. If the management staff determines that additional benefits are payable under the terms of the Plan, your Appeal is responded to and payment is made within 30 days of the receipt of your Appeal.

In all other cases, the Claim Committee of the Chicago Laborers’ Welfare Fund Board of Trustees will review your Appeal. The Committee currently meets on the first Tuesday of every month.

After the Claim Committee receives your written request, a determination on your Appeal, for:

Health Care Claims will generally be made within 30 days of receipt of the Appeal and the written decision will be mailed to your last known address no later than 60 days after your Appeal is received.

Disability Claims will generally be made within 45 days of receipt of the Appeal. If special circumstances require an extension of time, you will be notified within the 45-day Appeal determination period that up to an additional 45 days (no more than 90 days total from receipt of the Appeal) may be necessary. The written decision will be mailed to your last known address within five days after the decision is made.

Other Benefit Claims will generally be made within 60 days of receipt of the Appeal. If an extension is necessary, the Claimant will be notified within the 60-day Appeal determination period that up to an additional 60 days (no more than 120 days total from receipt of the Appeal) may be necessary. The written decision will be mailed to the Claimant’s last known address no later than 60 days (or 120 days if an extension is necessary) after receipt of the Appeal.

The Trustees will issue a written decision reaffirming, modifying, or setting aside the action you are appealing. The Trustees’ decision will be based on all information used in the initial determination as well as any additional information submitted. If your Claim is not paid in full, the written decision will include:

The specific reason or reasons for the decision;

Reference to the specific Plan provisions on which the decision was based;

A statement notifying you that you have the right to request a free copy of all documents, records, and relevant information; and